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CASE REPORT
Year : 2015  |  Volume : 24  |  Issue : 2  |  Page : 195-197  Table of Contents     

Use of electroconvulsive therapy in an elderly after 5 weeks of myocardial infraction with 30% cardiac output


1 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Anaesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication4-May-2016

Correspondence Address:
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-6748.181725

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   Abstract 

There is limited literature on the use of electroconvulsive therapy (ECT) in patients with recent myocardial infarction and in those with reduced cardiac output. In this report, we describe the safe use of ECT in a 70-year-male suffering from severe depressive episode with psychotic symptoms. He had a history of poor response to adequate pharmacotherapy and had suffered from myocardial infraction (MI), about 3 weeks prior to admission to the psychiatric unit. In view of severe depression associated with marked anxiety, agitation, psychotic symptoms, and poor food intake he was started on ECT after 5 weeks of MI when his cardiac output was only 30%. He received nine sessions of ECT without any cardiac complications and his depression remitted with ECT.

Keywords: Elderly, electroconvulsive therapy, low cardiac output, myocardial infraction


How to cite this article:
Grover S, Suchendra K, Mehra A, Parkash V, Saini V, Bagga S. Use of electroconvulsive therapy in an elderly after 5 weeks of myocardial infraction with 30% cardiac output. Ind Psychiatry J 2015;24:195-7

How to cite this URL:
Grover S, Suchendra K, Mehra A, Parkash V, Saini V, Bagga S. Use of electroconvulsive therapy in an elderly after 5 weeks of myocardial infraction with 30% cardiac output. Ind Psychiatry J [serial online] 2015 [cited 2020 Feb 23];24:195-7. Available from: http://www.industrialpsychiatry.org/text.asp?2015/24/2/195/181725

Due to initial reports of coronary accidents during electroconvulsive therapy (ECT),[1] the presence of cardiac problems is considered as a relative contraindication for administration of ECT. Accordingly, there is a need to weigh the pros and cons of using ECT in patients with cardiac problems such as recent myocardial infraction (MI), low cardiac output, and cardiac rhythm disturbances. There are very few reports of successful use of ECT among patients with recent MI [2],[3] and low cardiac output.[4],[5],[6] Accordingly, there is a need to expand the literature. In this report, we present the case of a 70-year-male, who received nine sessions of ECT after 5 weeks of MI when his cardiac output was only 30%.


   Case Report Top


A 70-year-old man presented with MI to cardiac unit and was referred to consultation-liaison psychiatric services for evaluation of depression. On evaluation, he was found to have an insidious onset illness of 4 years duration precipitated by a psychosocial stressor, with progressive and deteriorating course fulfilling the diagnostic criteria of severe depressive episode with psychotic illness. Exploration of the history revealed that after the stressful event, he developed symptoms of sadness of mood, crying spells, anhedonia, easy fatigability, anxiety, decrease in sleep and appetite, poor attention and concentration, ideas of hopelessness, worthlessness, and guilt. Over the years, his symptoms kept on increasing and by about 1 year of onset of symptoms, additionally he developed ideas of sin, poverty, death wish, and suicidal ideations. During this period, he lost a significant amount of weight and had melancholic symptoms such as morning worsening of sadness and waking up 2 h before his usual time (besides difficulty in falling asleep). Over the next 1 more years, his depressive symptoms worsened further, and he additionally developed delusion of persecution, delusion of reference, and delusion of poverty. After 3 years of onset of symptoms, he was first seen by a psychiatrist and was prescribed tablet escitalopram 10 mg/day along with the tablet propranolol 20 mg/day and tablet zolpidem 12.5 mg/day. The patient continued to take these medications regularly for the next 4 months without any improvement in his symptoms although did not experience any side effects. After this, he received adequate trials of sertraline (50 mg/day for 3 months), combination of sertraline (50 mg/day) and mirtazapine (15 mg/day) for 2 months, and combination of sertraline (50 mg/day) and olanzapine (10 mg/day) for 6 months.

While on sertraline and olanzapine he developed MI and on angiography was found to have severe left coronary artery stenosis (80%). He was managed conservatively with tablet clopidogrel 75 mg/day, tablet atorvastatin 40 mg/day, tablet aspirin 150 mg/day, and tablet ramipril 2.5 mg/day. His cardiac status stabilized, following which he was discharged from the cardiac unit and was admitted under psychiatric services after about 1 month of the event of MI due to continuation of depressive symptoms.

Throughout the symptomatic phase there was no history suggestive of symptoms of mania, hallucinations in any modality, features suggestive of delirium, substance use, head injury, seizures, or thyroid dysfunction. Mental status examination at the time of admission to psychiatric inpatient revealed sadness of mood, marked anxiety, restlessness, agitation, ideas of hopelessness, death wish, delusion of guilt and poverty, and preserved cognitive functions. Physical examination did not reveal any abnormality. His routine investigations in the form of hemogram, renal function test, liver function test, serum electrolytes, fasting blood glucose levels, serum Vitamin B12 and folate levels, and chest X-ray did not reveal any abnormality. His electrocardiogram revealed the presence of pathological Q waves along with T wave inversion suggestive of an old MI. His magnetic resonance imaging study of the brain revealed diffuse cerebral atrophy with small vessel ischemic changes. Initially, he was managed with an increase in the dose of tablet. Sertraline from 50 mg/day to 75 mg/day, change of antipsychotic from olanzapine 10 mg/day to quetiapine up to 100 mg/day and tablet alprazolam 0.5 mg twice daily. Tablet ramipril 2.5 mg/day, tablet metaprolol 12.5 mg/day, tablet. Ecosprin 150 mg/day, tablet atorvastatin 20 mg, and tablet clopidogrel 75 mg OD were continued. However, there was no improvement in his depressive, psychotic, and anxiety symptoms. His food intake was very low. In view of the poor response to the medications in the past, patient and family were offered ECT. After obtaining the consent of the patient and family members, he was evaluated for ECT. He underwent an echocardiography study which revealed that patient's left ventricular ejection fraction was only 30%. Patient and family were appraised about the situation, and high-risk consent was obtained, and the patient was started on modified bilateral ECT with the use of atropine as preanethetic medication, thiopentone for induction and succinylcholine used as a muscle relaxant. Over the period of 3 weeks, patient received nine effective ECTs, his Hamilton depression rating scale score reduced from 37 to 8 and ECTs were stopped after the response over the last 2 ECTs plateaued. Throughout the period when he was receiving ECT, on the day of ECT, after each ECT, patient cardiac status was monitored for 4 h after each ECT. No complications were seen with ECT except for minor cognitive deficits. Over the next 2 weeks, symptoms reduced further and the patient was discharged on tablet sertraline 75 mg/day and tablet quetiapine 200 mg/day along with the continuation of medications for physical problems. Patient has been maintaining well for 3 months after discharge and is functioning well.


   Discussion Top


Use of ECT is associated with an increase in cardiac output, rise in blood pressure, and increase in heart rate for few minutes.[4] Accordingly, a thorough cardiac evaluation is considered to be mandatory prior to the use of modified ECT. In general, the guidelines given by the American College of Cardiology/American Heart Association for noncardiac procedures requiring general anesthesia are followed for ECT too.[2],[7] These guidelines suggest that acute MI in last 1 week or severe MI in last 4 weeks is associated with an increase in perioperative morbidity. Accordingly, it is recommended to wait for 4–6 weeks after MI to perform elective procedures. However, there are case reports of the use of ECT in the above specified high-risk period too. We searched the Medline for reports of the use of ECT after MI and came across only 2 case reports. In a case report, authors reported the successful use of ECT after 10 days of MI in a 76 old subject.[2] In another case report, the patient was administered ECT 30 days after the MI.[8] There are reports of myocardial stunning after the use of ECT.[9]

In terms of use of ECT in patients with reduced cardiac output, again the data are sparse. Besides occasional case reports,[5],[6] only one study has presented the data of 35 patients.[4] According to this study, ECT was used in 35 patients, aged 54–92 years with cardiac output ranging from 15 to 40% without any cardiac complications such as decompensated heart failure, myocardial ischemia, or MI, either during the ECT procedure or 24 h after an ECT session.[4] However, nonlife-threatening cardiac arrhythmias were seen in 3 patients. Those patients who developed marked hypertension during the ECT sessions were prophylactically given beta-blockers prior to next ECT sessions.[4]

Our patient was suffering from severe depression, who had marked restlessness and agitation, which did not respond to pharmacological measures. In view of these ECT was considered. Our case can be considered as unique as the cardiac output of patient was only 30%, and he had a recent MI. Our case suggests that ECT can be safely given in patients with recent MI and/or reduced cardiac output with proper monitoring. Our case adds to the limited literature of safe use of ECT in patients with recent MI and reduced cardiac output.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Hussar AE, Pachter M. Myocardial infarction and fatal coronary insufficiency during electroconvulsive therapy. JAMA 1968;204:1004-7.  Back to cited text no. 1
    
2.
Magid M, Lapid MI, Sampson SM, Mueller PS. Use of electroconvulsive therapy in a patient 10 days after myocardial infarction. J ECT 2005;21:182-5.  Back to cited text no. 2
    
3.
Aloysi AS, Maloutas E, Gomes A, Kellner CH. Safe resumption of electroconvulsive therapy after non-ST segment elevation myocardial infarction. J ECT 2011;27:e39-41.  Back to cited text no. 3
    
4.
Rivera FA, Lapid MI, Sampson S, Mueller PS. Safety of electroconvulsive therapy in patients with a history of heart failure and decreased left ventricular systolic heart function. J ECT 2011;27:207-13.  Back to cited text no. 4
    
5.
Rayburn BK. Electroconvulsive therapy in patients with heart failure or valvular heart disease. Convuls Ther 1997;13:145-56.  Back to cited text no. 5
    
6.
Krahn LE, Rummans TA, Ryan D, Oconnor MK. Use of electroconvulsive therapy for depression coexisting with congestive heart failure. Psychosomatics 1997;38:197.  Back to cited text no. 6
    
7.
Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery – Executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 2002;105:1257-67.  Back to cited text no. 7
    
8.
Ungerleider JT. Acute myocardial infarction and electroconvulsive therapy. Dis Nerv Syst 1960;21:149-53.  Back to cited text no. 8
    
9.
Go O, Mukherjee R, Bhatta L, Carhart R Jr., Villarreal D. Myocardial stunning after electroconvulsive therapy in patients with an apparently normal heart. J ECT 2009;25:117-20.  Back to cited text no. 9
    




 

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